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Gender and health status of women in Turkey/Turkiye'de toplumsal cinsiyet ve saglik durumu.

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Turkiye'de Toplumsal Cinsiyet ve Saglik Durumu

Dunyanin pek cok bolgesinde oldugu gibi Turkiye'de de kadina atfedilen toplumsal cinsiyet rolleri toplum tarafindan icsellestirilmekte ve cok cesitli bicimlerde ve alanlarda yeniden uretilmektedir. Turkiye'de yasal duzeyde kadin-erkek arasinda goreli bir esitlik saglanmissa da hem kamusal hem de ozel alana bakildiginda kadinlarin toplumsal cinsiyete dayali esitsizliklerle karsi karsiya kaldigi gorulmektedir. Ancak, sorunun gercek anlamda analizlerinin ortaya konulabilmesi icin toplumsal cinsiyet tabanli calismalarin yasamin tum alanlarmda surdurulmesi gerekmektedir. Bu makalede, kadinin statusunu ve saglini etkileyen bazi faktorlerin toplumsal cinsiyet bakis acisi ile incelenmesi amaclanmishr. Turkiye'de kadinin durumunu ve bu durumun sacjhga yansimalarini ortaya koyan bazl gostergeler araahgl ile konu tartisilmishr.

Anahtar Kelimeler: toplumsal cinsiyet, saglik, kadin, Turkiye.

Abstract

In Turkey, gender roles, which are attributed to women, are unquestionably and unperceptively accepted and internalised by the society as well as in other societies. The health status of women is an outcome of women's social status, which is highly determined by gender roles. Although women in Turkey have relatively equal legal rights, they face inequalities in public and private spheres. Therefore, it is necessary to analyze the gender-based inequalities in order to understand the problems of women in relation to health. In this paper, factors which determine and influence the status of women and women's health in Turkey, will be examined by a gender perspective. Women's status and its impacts on health are discussed by using some indicators acquired both in Turkey and in other countries.

Key words: gender, health, women, Turkey.

Introduction

The gender based inequalities and discrimination against women influence both the living conditions and health status of women in a negative way. "Health" is defined as "a state of complete physical, mental, social and spiritual well-being" by the World Health Organization (WHO) (Fisek, 1988). Every individual has right to good health regardless of language, ethnicity, gender and other differences. However, there are physical, biological, cultural differences and socio-economic inequalities between men and women, which might have depressing implications on the health status of women (Dedeoglu, 1992).

There is a growing interest in the relationship between women's status and its influence on women's life conditions and health during the last decades by the developments and increased sensitivity regarding gender and development issues in the international forum. "The women in development approach" which seeks to integrate women into development processes more actively is also being applied in the area of health. The programs and policies focusing on "maternal and child health" have been important examples for this development. However, the focus on maternal and child health is still problematic since its emphasize has been on women's reproductive health excluding other aspects of women's health.

A "gender" approach was developed to address the inequalities and discrimination, which women face and their underlying causes through a wider analysis of gender roles in order to understand their influences on the status of women. A gender analysis was also integrated in programs on women's health. This approach aims to reveal the relationship between gender based inequalities and discrimination and the disadvantages that women face in health. It also highlights that various situations such as women's educational and social status, reconciliation with their social role, workload, income status, professional risks, participation in the social and activities in development, decision-making roles within the family, attainment to health care services can influence their health problems either directly or indirectly (Sacakhoglu, 1996).

It is quite difficult to assess and abstract gender-based socio-economic inequalities individually through standard and measurable indicators. However, there are two indexes (Gender Based Development Index-GBDI, and Gender Based Participation Criterion-GBPC) through which gender based inequalities, women's status and gender-based discrimination, can be measured. GBDI depends on the data of approximate lifespan, adult literacy and schooling rates of men and women with their participation in employment and income levels. The level of participation in political decisions is assessed by the ratio of seats in the National Assembly and their vocational participation level is measured by their portion in both technical and executive positions. GBPC is calculated by dividing the sum of each of these three related indexes by three. Due to the lack of data, the participation of women in local governments is not included. The minimum rate that GBDI and GBPC can reach is "0" and the maximum is "1 ". Turkey ranks the 45th with a 0.74 GBDI rate and 98th with a 0.24 GBPC rate among 130 countries (Senesen, 1998).

In spite of the legal equality provided to women in the Turkish Republic due to the modernization process, the gender inequalities still shape the status and life conditions of women in several spheres of life that directly make women disadvantaged group. For instance, in 1990 half of the women in Eastern Turkey were illiterate as opposed to 21.6 % of men. These rates were lower in Western Turkey where 19.7% of the women and 7.4% of men were illiterate (Ilkkaracan, 1998). The inequalities that women face regarding access and utilization of health care reflects the gender inequalities in Turkey. In this paper, the factors, which determine and influence the status of women and women's health in Turkey will be discussed.

The Status of Women in the World

Gender based inequalities arise from the gender roles of women and men, and the unequal power relationships between them. As with gender itself, these inequalities are socially constructed. They have significant influences on women's life conditions and health status. Although there are several improvements in terms of the recognition of the necessity of gender equality for the improvement of women's status, gender discrimination still exists in both developed and developing parts of the world. Education and employment are the two basic areas that influence the women's status directly and their position in power relations both in public and private spheres, the gender inequalities in these areas are elaborated below.

Participation in economic life is one of the areas where gender based inequalities are evident. Women face gender based discrimination in terms of employment opportunities. Due to their traditional gender roles at home, they are excluded from the participation in income generating activities. They are obliged to work in certain areas. Although they have the same education level and experience, they are paid lower wages with less opportunity for promotion. It is very noteworthy that although women represent half of the (50%) world population and fulfill two-thirds (66%) of working hours, they share only one-tenth (10%) of the world revenue and have less than 1% of the world property (Tanritanir, 1995). In many countries, women do not only earn less than men in their line of business but also experience a process devoid of income guarantee known as the "feminization of poverty" (Working Women, TURK-J$). In comparison with men, the number of women who live in poverty has increased disproportionately for the last ten years, particularly in the developing countries. The identification of poverty with women as a consequence of political, economic and social transformation in the short run has been an important issue especially in countries of economic transition. Poverty affects the whole household. However, due to the gender division of labor, women's primary responsibilities are the ones concerning the welfare of the household so the burden of women is much heavier because they try to manage the consumption and production of the household in increasingly destitute situations (The Turkish General Directorate, 1995). The education of women is also one of the measures of their status. Improvement of educational facilities and equal education opportunities for girls and boys has been one of the targets of development in most countries. However, the actual situation is very poor. In 1990, the number of children who did not receive primary education reached 100 million worldwide. Girls constitute 60% of this figure. Throughout the world, there are 960 million illiterate adults of whom 640 million are women (Tanntanir, 1995).

The gender based power relations and inequalities within society and at home fosters women's loss of control over their own health and less access to means necessary to protect their health. Women are often the primary carers in the health sector as a consequence of their traditional gender roles as mothers and carers at home. Yet, women do not have equal opportunities in attaining the fundamental health resources including the primary health services which are organized to prevent and treat childhood diseases, malnutrition, anaemia, diseases related with diarrhea, malaria, and their utilization of these opportunities vary (The Turkish General Directorate, 1995).

The social realities, which influence the health of women, are widespread poverty, economic dependency, exposure to violence and negative attitudes towards women and girls. Race, ethnicity or other types of discrimination, have limited the power over her own sexual life and fertility and participation in the decision making process (The Turkish General Directorate, 1995).

The relationship between the status of women and her reproductive health has started to be discussed recently. In societies where they are valued in accordance with the number of children they give birth to, women have difficulty in controlling their fertility. According to research which studied the relationship between women's status and their fertility, in countries where the status of women is very low, the "Total Fertility Rate" has been found to be higher than in the countries where the status of women is very high (Ozvaris, 1998). There is a similar relationship between fertility rate and women's health. As the fertility rate of women increases, they are more inclined to being ill and this gives rise to an increased risk of disorders or deaths. However, this relationship should not be limited to only the relationship with the social status-fertility-health but it is a more complex structure that needs further gender analysis.

The inequalities faced by women in health are highly influenced by the economic development. The average woman in the U.S. or Europe attends at least antenatal sessions with a skilled provider; maintains a healthy diet and make plans about her birth, including an institution-based delivery with a skilled provider. In contrast, the average African or Asian woman attends one or two antenatal visits with a skilled provider; may not have money to eat a proper diet, may have infectious disease that is not properly treated during her pregnancy; and usually does not make plans for delivery. Most women in the U.S. deliver in a health facility, so if a complication arises it is easy to treat. If she has not yet reached the health institution and a complication arises, most women know the danger signs and can make the decision to get help. She knows where to go to get help and when she arrives at the hospital, she is treated promptly by trained personnel and a health care system that is well equipped to deal with her emergency. On the other hand, most women in the developing world usually deliver at home with the help of her mother-in-law or an older woman in the community. If a complication arises, a majority of them do not know the danger signs and do not recognize these early enough to save their life (Rae, 1998).

The level of development of countries influences the position and health of women closely. In Table I, some criteria of certain developed countries and Turkey are indicated (Tanntanir, 1995). Turkey falls considerably behind. There seems to be an improvement in health as the level of development rises. For instance the total fertility rate has been found to be 2.6 in Turkey, 2.1 in United States, 1.8 in Australia and 1.3 in Germany. There is a marked difference in the other indicators between Turkey and the other countries (Table I).

The Status of Women in Turkey

Women in Turkey were granted equal legal rights in the post-Republican era at a time before many other countries in the world. The modernization project of the Turkish republic requires the evolution of independent, contemporary, and "Western" woman citizens with high qualifications and visibility in public life. The rights granted to women can be examined in four domains: education, law, politics and civil issues (Akin A, 1998).

The law on education was enacted on the 3rd March 1924 and by the Civil Code in 1926 the reform was supported. However, by 1998 the gap between the literacy rates of men and women remained. In 1996-97 school year, the share rates of the male enrolments in middle and equivalent schools was 53.9% (The Turkish General Directorate, 1999).

According to the results of a 1998 Demographic and Health Survey of Turkey (TDHS) (the latest nationwide survey), these figures are 55.1% for women and 73.7% for men. In accordance with the same survey, 10.7% of males are uneducated and 19.4% are graduates of middle and higher schools. There are also regional differences in respect to educational level. For instance, while in eastern regions 46.5% of women are uneducated, this proportion is only 17% in the western regions. The rate of women who have never Been to school in the rural areas is 33.1%; in the urban areas this percentage is 20.9% (Turkish Demographic and Health Survey, 1998).

The increase of compulsory education from 5 years to 8 years by 1997 has been very significant step in female education. However, a decisive attitude should be adopted to improve girls' continuation in education. The unchanged, unequal situation of women in education, despite the 79-year-old laws, is a social fact requiring attention. As stated by the Population Survey of 1990, 45% of women who are within the scope of the South-Eastern Project are illiterate. While only 71% of the school aged children go to the primary school, 28% attend secondary school, 18% go to the high school and approximately 1% have education at the university (Cakmak, 1998).

The first legal treatment of women was the 1930 "Municipality Act". It was 1934 that every Turkish citizen, men or women had the right to elect and be elected. In 1935, the year of the first elections in the Republic of Turkey, a total of 18 female deputies entered the parliament.

Although Turkey, has been one of the pioneer countries in absorbing the principle of equality between sexes both into the constitution and into other laws, due to the disadvantageous position of women in decision-making mechanisms, these advancements could not have Been reflected in the social/political life completely (KIDOG, 1997). Women have equal rights regarding voting and elections, but they cannot participate in active political life by being elected because of their powerless status in institutional politics.

In Turkey, women do not consider politics as one of their functions. Their traditional roles in society is an obstacle to attain their political rights in a competition struggle within and between the parties. Thus due to the political arena being very tough, this prevents women from entering the field of politics and forces them to stay behind (KIDOG, 1997). Consequently, the social and economic position of women is not equivalent to their legal gains but rather keep them back.

At present, the position of women in work life, particularly in labour force, is well-recognised by the many sectors of the society. However, as in the rest of the world, their employment is limited to certain sectors with the worse working conditions and lower wages. According to the 1996 State Institute Statistics data, women are intensively employed in the agricultural sector (The Turkish General Directorate, 1999). As shown by the same data, the majority of the employed women work as an "unpaid family worker": According to the results of TDHS-1998, 49% of women work in agriculture and 6 out of 10 women work on her own family field. In the agricultural sector, women are employed mostly as unpaid family workers in comparison to men (Table II).

The Health Status of Women in Turkey

Following the 1994 United Nations International Conference of Development and Population (ICDP), a "holistic', "life-cycle" approach in women's health has been adopted in respect to the continuity of health care services. Taking the life stages of women into account, this approach aims to address the health problems of women from a much earlier stage to the childhood, adolescence, fertility, to menopause--post menopause and old age stages and requires the provision of services in a "continuity" including all of these life stages.

When the health of women in Turkey is examined by "life-cycle approach", significant health problems specific at each period from birth to death should be highlighted such as sex preference at birth; adolescence pregnancies due to marriage at early ages; risky pregnancies, multiple pregnancies at the fertile ages; and the problems that women face at menopause and post-menopausal periods.

In Turkey, the regional differences deepen the problems of women's health. The socio-economic inequalities between the regions, as well as gender inequalities, determine the health status of women. The low social and economic status of women, especially those who live in the rural areas and Eastern regions, compared to those who live in the urban areas and western regions have adverse effects on their health. In spite of this fact no particular widespread program is implemented for the promotion of women who live in the rural areas and Eastern regions except for some small-scaled local studies.

Nutrition problems, problems related with fertility, violence against women, sexually transmitted infections, professional diseases, cervix and breast cancer are some of the common health problems of women in Turkey (Sacaklioglu, 1996).

Some Figures Due to Health Problems of Women in Turkey

In a survey carried out in 1997 covering 615 hospitals in 53 cities in Turkey, maternal mortality rate was found to be 54 per one hundred thousand (Mihciokur, 1998). According to 1998 TDHS, the total fertility rate is 2.6. However, this figure was found to be 4.2 in the Eastern region and 2.0 in the Western regions. While a significant number of births take place at a health unit (72.5%), the proportion of women who receive antenatal care is 67.5% in the East and 13.9% in the West. The recognised disparity between the regions in almost every aspect is also striking. Births delivered by trained personnel are 80.6%, the rate of voluntary termination of pregnancy is 14.5%. The rate of using any family planning method including traditional and ineffective methods is 63.9%. Also, the rate of using any modern family planning method is 37.7%. The rate of births delivered by trained health personnel is 92.3% in the West while it is 52.3% in the East (Turkish Demographic and Health Survey, 1998).

Utilization of Antenatal Care Services

Although there has been some significant progress over a period of years, there are some drawbacks for women who live in the rural areas and Western regions. These drawbacks are the presence, delivery and acceptability of the primary health care services (primary health centers) specifically in the antenatal care and safe delivery conditions. Antenatal care is a very important intervention in reducing maternal and newborn mortalities. In Turkey, husband education, mother's education, mother's health insurance, mother's age, desire for pregnancy, birth order, ability to speak Turkish, having a civil marriage are significant determinants of having higher antenatal care. Twenty six per cent of women living in the South-East region have never attended to hospital. Fifty six per cent of women stated that they did not have any such need. Unless they have poor health and are under a heavy health risk, women do not demand any health service due to cultural and economic factors. One of the underlying obstacles to women to attain health services is that they are unwilling to be physically examined by "male" doctors (Akin, 2002).

The educational status of women and the place of residence (urban/rural/ West/East) are determining factors, particularly in the issues related to the attitudes of fertility and utilising health care services, receiving antenatal care and giving birth in health care institutions. Additionally, factors such as the inadequate number of the health care services (village clinics), the imbalance in the distribution of personnel, and the lack of professional knowledge and skill of the personnel as well as the language barrier particularly for the women in the East, influence utilization of these services adversely (Akin, 2002).

Violence Against Women

One of the most frequent and concrete issues of gender discrimination is violence against women, which has direct health consequences. Violence against women is defined as "the most common and identified human rights abuse". In developing countries 20-50% women are the victims of physical assaults by their husbands (UNFPA, 1997).

In Turkey, violence is a frequent incident. Some of the health problems which an individual faces through violence can be listed as: injuries, depression, undesired pregnancies, fear, gynaecological problems, anxiety, AIDS-diseases from sexual intercourse, inferiority complex, abortions, nutritional problems, pelvic inflammatory diseases, obsessive-compulsive attitudes, chronic pelvic pains, problems related with post traumatic stresses, developing bad habits like smoking, alcohol and drug addiction (Ozaydin, 1998).

Conclusion and Recommendations

The health problems of women are not one-dimensional. It is necessary to understand the influences of gender on women's health, and integrating a gender approach in policies and programs. WHO has adopted an approach sensitive to gender discrimination. The adopted approach is based on gender and includes the following points:

i. To adopt a more extensive approach when dealing with the factors that influence women's health and to consider not only the biological factors but the social and economic status, as well as cultural, environmental, familial, professional and political factors as well,

ii. To adopt an approach which takes up women's roles not only as mothers or spouses but all their roles as a whole,

iii. To study the roles of men and their responsibilities together with the inequalities between men and women in context with the sensitivity to the health of women.

iv. In identifying health problems, to realise the initiatives which will give women a voice in planning and following up on these problems.

In conclusion, although there have been some improvements in the health of women with health care services in the short run, if a radical solution on this issue is desired, in the long term, the most important undertaking should be directed to the promotion of women's education and raising their status. If the status of women improves, the disadvantages experienced in every aspect will decline. However, raising the status of women is a long-term project. The prerequisite for pursuing this long path is to have a holistic approach, which will cover the factors influencing the status of women together with the solutions.
Table 1: Some Criteria that linfluence women's Status and Health

Indicators Turkey USA

Total Fertility Rate (1996) 2.6 2.1
(The World Bank Report, 1997)
Crude Birth Rate (%) 27.3 15.9
(WHO)
Education Level 72.4 99.0
The Literate Rate(%)
(WHO)
Attending assistance from educated 45.0 98.3
personnel during pregnancy (%)
(WHO)
Attending assistance from educated 76.0 99.0
personnel during delivery (%)
(WHO)
Maternal Mortality Rate ('00 000) 54 **
(WHO, 1997)
Place of country in mortality rate under 81 159
5 (UNICEF 1999) *
 Australia Germany
Indicators
 1.8 1.3
Total Fertility Rate (1996)
(The World Bank Report, 1997) 14.8 9.9
Crude Birth Rate (%)
(WHO) 82.0 98.9
Education Level
The Literate Rate(%)
(WHO) 100.0 99.0
Attending assistance from educated
personnel during pregnancy (%)
(WHO) 99.0 100.0
Attending assistance from educated
personnel during delivery (%)
(WHO) 9 22
Maternal Mortality Rate ('00 000)
(WHO, 1997) 171 181
Place of country in mortality rate under
5 (UNICEF 1999) *

* As the mortality rate under 5 rises, their sequence falls. This value
is used for comparison.

** In a research carried out in 615 maternity hospitals in Turkey in
1997, maternal mortality rate is 54('00 000) (Mihciokur, 1998). The
other maternal mortality rate values are from WHO, 1997.

Table II: Employed Person by Economic Activity * (%)

 October 1990 October 1998

 Women Men Women Men

Agriculture 75.8 33.6 70.0 32.6
Industry 9.8 26.8 10.6 27.2
Services 14.4 39.6 19.4 40.2

* Results of Household Productive Labour Force, (State Institute
Statistics data) (Turkish General Directorate, 1998)


References

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Mihciokur, S. & Akin, A. (1998). Dunyada ve Turkiye'de Anne Olumleri, Saglik ve Toplum Dergisi, 3-4, pp. 37-44.

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Dilek Aslan, Dilek Aslan (MD), Lecturer, Hacettepe University, Faculty of Medicine, Department of Public Health, 06100, Sihhiye, Ankara, Turkey (e-mail address: daslan@superonline.com or diaslan@hacettepe.edu.tr)

Sevkat Ozvaris, Assoc. Prof. Dr. Sevkat Bahar Ozvaris (MD.) Hacettepe University, Faculty of Medicine, Department of Public Health.

Cigdem Esin, Cigdem Esin, Sociologist, Hacettepe University, Faculty of Medicine, Department of Public Health
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Author:Aslan, Dilek; Ozvaris, Sevkat; Esin, Cigdem
Publication:Kadin/Woman 2000
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Date:Jun 1, 2003
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